University of North Dakota UND Scholarly Commons Physical Therapy Scholarly Projects Department of Physical Therapy 2009 Use of Aquatic Therapy/Core Stabilization and a Multi-Disciplinary Treatment for a Patient with Chronic Low Back Pain: A Case Report Jesse Elis University of North Dakota Follow this and additional works at: https://commons.und.edu/pt-grad Part of the Physical Therapy Commons Recommended Citation Elis, Jesse, "Use of Aquatic Therapy/Core Stabilization and a Multi-Disciplinary Treatment for a Patient with Chronic Low Back Pain: A Case Report" (2009). Physical Therapy Scholarly Projects. 515. https://commons.und.edu/pt-grad/515 This Scholarly Project is brought to you for free and open access by the Department of Physical Therapy at UND Scholarly Commons. It has been accepted for inclusion in Physical Therapy Scholarly Projects by an authorized administrator of UND Scholarly Commons. For more information, please contact [email protected]. USE OF AQUATIC THERAPY/CORE STABILIZATION AND A MULTI- DISCIPLINARY TREATMENT FOR A PATIENT WITH CHRONIC LOW BACK PAIN: A CASE REPORT By Jesse Elis Bachelor of Science in Physical Therapy University of North Dakota, 2007 A Scholarly Project Submitted to the Graduate Faculty of the Department of Physical Therapy School of Medicine University of North Dakota In partial fulfillment of the requirement for the degree of Doctor of Physical Therapy Grand Forks, North Dakota May, 2009 This Scholarly Project, submitted by Jesse Elis in partial fulfillment of the requirements for the Degree of Doctor of Physical Therapy from the University of North Dakota, has been read by the Advisor and Chairperson of Physical Therapy under whom the work has been done and is hereby approved. (Graduate School Advisor) (Chairperson, Physical Therapy) ii PERMISSION Title Use of Aquatic Therapy/Core Stabilization And A Multi-disciplinary Treatment For A Patient With Chronic Low Back Pain: A Case Report Department Physical Therapy Degree Doctor of Physical Therapy In presenting this Scholarly Project in partial fulfillment of the requirements for a graduate degree from the University of North Dakota, I agree that the Department of Physical Therapy shall make it freely available for inspection. I further agree that permission for extensive copying for scholarly purposes may be granted by the professor who supervised my work or, in his absence, by the Chairperson of the department. It is understood that any copying or publication or other use of this Scholarly Project or part thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and the University of North Dakota in any scholarly use which may be made of any material in this Scholarly Project. Signature Date iii TABLE OF CONTENTS LIST OF TABLES …………………………………………........................................v ACKNOWLEDGEMENTS…………………………………………..…........................vi ABSTRACT ………. ………………………………………….….................................vii CHAPTER I. BACKGROUND AND PURPOSE………………………...........1 II. CASE DESCRIPTION…………………………...........................8 Examination, Evaluation and Diagnosis.......................................10 Prognosis and Plan of Care……………........................................13 III. INTERVENTION……………………………………….............15 IV. OUTCOMES…………………………………………................21 V. DISCUSSION………..……………………................................25 Reflective Practice…………………………….............................26 REFERENCES ……..………………………………………….......................................29 iv LIST OF TABLES 1. Initial Assessment of Trunk ROM ……………………………………........................11 2. Pool Therapy………………………………………………….................................19-20 3. Final Assessment of Trunk ROM (Aquatic therapy)……………………….................23 4. Final Assessment of Trunk ROM (Work Fit)………………………….……...............24 v ACKNOWLEDGEMENTS I would like to acknowledge and extend my heartfelt gratitude to the following persons who have made the completion of this case report possible: My mother for the help and inspiration she gave to me to succeed in college. My finance, Mickallyn, for the constant reminders and much needed support All the UND faculty members and staff for providing me with great education Most especially to my family and friends And to God, who made all things possible vi ABSTRACT Background and Purpose: This case report describes the use of two different conservative treatment approaches on a patient suffering from chronic nonspecific low back pain. The case report illustrates the difference between aquatic therapy/core stabilization, which focuses on the biological aspect of the injury, and multi-disciplinary treatment, which treats the injury on a biopsychosocial level. Case description: The patient was a 32-year old man that suffered two disc herniations from lifting a large box at work. After the injury, the patient received conservative treatments 3 months prior to this specific case report. Neurological deficits were present and the patient had positive results in multiple neural tension tests. Intervention: The patient completed four weeks of aquatic therapy/core stabilization and had minimal results in functional mobility and pain relief. After aquatic therapy, the patient was referred to a multidisciplinary treatment program called Work Fit, which focused on improving function through pain management. Outcomes: One month of Work Fit resulted in complete recovery of trunk ROM, decreased pain, improved sleeping habits, and good body mechanics with functional movement. Discussion: In regards to this specific patient, the multidisciplinary approach was very successful in the management of chronic back pain. The multidisciplinary program restored normal function of the patient’s back through physical and psychological exercises. vii CHAPTER 1 BACKGROUND AND PURPOSE Despite being one of the most commonly treated injuries in outpatient physical therapy, management of mechanical low back pain is still considered a challenging disorder to treat. As noted by Brotzman,1 mechanical low back pain (LBP) affects between 70% to 85% of American adults at some point in their lives and is considered the most common disability in patients younger than 40 years. With regards to the healing process, 90% of LBP patients have symptom resolution within six weeks and another 5% have symptoms resolved by 12 weeks.1 Persistent back pain lasting longer than 3 months is considered a chronic injury, and the patient’s prognosis of full recovery at that point begins to deteriorate.2 In this specific case study, the patient suffered from two separate disc herniations and had minimal symptom relief within the first 3 months following the injury. In general, after years of poor body mechanics the integrity of the spine begins to deteriorate and the intervertebral disc is one of the first tissues to fail. The intervertebral disc is made up of two components: the nucleus pulposus, a jelly-like material in the center, and the fibrous outer ring called the annulus fibrosis.2-3 A herniation occurs when the collagen fibers of the annulus fibrosis are unable to resist the unbalanced radial pressure of the nucleus pulposis. The posterolateral aspect of the disc is the weakest point and concurrent movements of flexion and rotation result in excessive stress to the 1 weak area. With the accumulation of pressure in the posterior disc, the nucleus pulposus begins to push through the distal annular fibers until it’s exposed within the spinal canal. Pain is a result from either the direct pressure of the disc lesion on the adjacent nerve root or the inflammatory mediators that attack the foreign disc material and irritate the nerve root. Nerve root irritation causes symptoms such as edema, warmth, redness, muscle weakness, pain, and paresthesia within the nerve root sensory distribution. When dealing with treatment options for a herniated nucleus pulposis, there are two different approaches: surgical and non surgical (conservative) approach. The most common surgical option is a lumbar discectomy, in which the exposed disc material and any additional bone impinging on the nerve root is removed.4 In regards to conservative treatment, there are a variety of options; such as physical therapy, chiropractic, and pharmeuctical agents (muscle relaxants, steroids, epidural injections). In general, conservative management includes maneuvers to reduce pressure on the nerve root and attempt to pull the exposed disc material back into the central disc space. One systematic review compared a surgical and a conservative approach in the treatment of degenerative disc disease, with the results showing surgery to be the superior choice compared to an unstructured conservative treatment; however a highly structured rehabilitation program with a cognitive-behavioral approach produced results similar to surgery.5 In addition, another article found there was no clear evidence that a spinal fusion was superior to an intensive rehabilitation approach and the long term effects showed no differences.6 Conservative treatment is always the more conventional option in treating injuries and the primary healthcare provider needs to determine which choice would be most 2 beneficial to the patient. The two treatments being assessed here are a combined rehabilitation program of aquatic therapy/core stabilization and a multidisciplinary approach. The reason for aquatic therapy/core stabilization was to attempt to reduce the disc lesion